Healthcare Provider Details

I. General information

NPI: 1083890123
Provider Name (Legal Business Name): SUSAN WILDERMANN MA, PD(MFT), LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2008
Last Update Date: 01/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 CLINTON AVE
BELFORD NJ
07718-1217
US

IV. Provider business mailing address

512 CLINTON AVE
BELFORD NJ
07718-1217
US

V. Phone/Fax

Practice location:
  • Phone: 732-895-7009
  • Fax: 732-787-3268
Mailing address:
  • Phone: 732-895-7009
  • Fax: 732-787-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00357000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: